Low-protein diet supplemented with ketoanalogues: The role of an integrated approach beyond the start of dialysis (Review)

The traditional paradigm of standardized thrice-weekly hemodialysis is being challenged by personalized incremental and decremental prescriptions aimed at preserving residual kidney function. In this scenario, nutritional therapy maintains a central role even following the onset of renal replacement therapy. The present narrative review synthesizes evidence up to February, 2026 on the efficacy of a low-protein diet (LPD; 0.6 g/kg/day) and very low-protein diet (VLPD; 0.3-0.4 g/kg/day) supplemented with ketoanalogues (KA). Compared to traditional Mediterranean or plant-based regimens, the LPD/VLPD + KA approach strictly minimizes uremic toxin generation, acid load and phosphorus retention, while maintaining a neutral nitrogen balance and preventing protein-energy wasting. In incremental protocols, this combination functions as a reducer of waste products, smoothing interdialytic solute peaks and shifting the gut microbiota away from proteolytic pathways such as indoxyl sulfate and p-cresyl sulfate. Crucially, as a proof of concept for dynamic care and as an emerging and hypothesis-generating approach, combining a safe metabolic workload reduction via LPD + KA with close monitoring allows for decremental dialysis strategies, which can aid in reducing session frequency as long as adequate native clearance is maintained. Consequently, this integrated approach may prove to be useful in reducing annual dialytic expenses. Finally, nephrology nurses act as the essential catalyst, translating these complex dietary restrictions into sustainable lifestyles that preserve patient compliance and quality of life.